Learn about front-line clinical informatics, clinical workflow design, and EMR implementation with an experienced CMIO. Open discussion is encouraged, education is a priority. All opinions are strictly my own.

Thursday, December 22, 2011

So I train a lot of doctors on electronic medical records. I'm always interested to learn how doctors think about their medication orders. How do they write them? Do they understand them? Do they know who reads them? How does that order get to the patient?

One of the areas of prescription writing I'm particularly interested in is the SIG: section of a prescription. (For some of the basics of a prescription, see this excellent Wikipedia article.)

"SIG" is medical shorthand for "Signa", which in Latin literally means, "write". In simple English, it basically means, "Please write these instructions for taking the medication : _________________"

(Huh? Why not just write "Instructions : _____________" - I mean, don't we have printed pads? Is ink too expensive?)

Anyway, some examples of "SIG:" shorthand commonly seen on prescriptions include :

SIG : 2 tabs PO q6h prn (IN ENGLISH : Two tablets by mouth every six hours as needed)

Why do doctors write this bizarre latin shorthand? I'm not sure, but it sure is short to write. For more details on this medical shorthand, Wikipedia has this article on prescription shorthand - Some of these I'm not even familiar with as a practicing physician.

Does this shorthand help patients understand how they're supposed to take their medications? Not really. So we need pharmacists and nurses and other health professionals who help interpret this.

As a linguist, I'm also puzzled - Here we have a writing that allows communication from doctor to pharmacist, and doctor to nurse, but not doctor to patient. Why does this language exist?

One of the more fascinating parts about this communication is that here seems to be some confusion about "BID", "TID", "QID", etc. versus q12h, q8h, and q6h.

First, some background about this :

QD - In Latin : Quaque Die - In English : means "Once a day"

BID - In Latin : Bis In Die - In English : means "Twice a day"

TID - In Latin : Ter In Die - In English : means "Three times a day"

QID - In Latin : Quater In Die - In English : means "Four times a day"

These are so pleasant, and potentially difficult to read (depending on handwriting), that they are falling out of favor and being replaced with their English equivalents.

Then, there is the q___{time} designation, like :

q2h = Every 2 hours

q4h = Every 4 hours

q6h = Every 6 hours

q8h = Every 8 hours

q12h = Every 12 hours

q24h = Every 24 hours

q48h = Every 48 hours

What I find interesting is the common question, "Should I write this medication QID or q6h?"

I. THE DIFFERENCE BETWEEN QID AND Q6H

Ever heard of the story of the patient who asks the pharmacist, "My doctor says I should take this medication four times a day - Does that mean I need to wake up in the middle of the night to take it?"

What this speaks to is some confusion about the difference between the two. Often, doctors use the two interchangeably. But while in most patients the clinical difference is minimal, they are very different to nurses and pharmacists. Here it is :

QD, BID, TID, and QID actually have very specific times attached to them.

QD = usually 08:00am

BID = usually 08:00am and 20:00pm

TID = usually 08:00am and 12:00noon and 20:00pm

QID = usually 08:00am and 13:00pm and17:00pm and 22:00pm

When I say usually, I mean it - Many hospitals have slight variations to this schedule. As an example of how challenging this can be, some hospitals publish their own standard medication timing guidelines like this which try to help standardize these times. Ask your hospital pharmacy what their standard med administration times are!

The one thing that is pretty standard about all of these (QD, BID, TID, QID) in virtually all hospitals is that, as much as they might vary, they're all usually during waking hours. None of them would technically let you take a dose at 4am.

q2h, q4h, q6h, q8h, q12h - DO NOT have specific times attached to them.

In other words, if you write to give a medication every 12 hours, the actual time it will be given will depend on what time you write the order : If you write it at 5am, then the medication will be given at 5am and 5pm. If you write it at 7am, then the medication will be given at 7am and 7pm.

Of course, if you wanted it to be given at 8am and 8pm, but you were writing the order at 5am, then you could write "q12h START TIME : 08:00am"

This is why it's not uncommon to see as-needed pain medications written as "TID PRN" - Many doctors are not even totally aware of the difference between TID and q8h. Of course, in most of these instances, if a patient were to go to the doctor and ask "Can I take it at 4am for pain if I need to?", the doctor would often say "yes".

Clear as mud? The good news is that with most medications, being an hour or two off means little in terms of the amount of drug in the blood - So it really doesn't make much difference from a clinical perspective.

But this language sure causes some confusion. Do we really need this Latin shorthand? Who is it helping?

II. RETHINKING THE SIG

So today at work, I was rethinking the sig :

And it's interesting - I noticed that in about 90% of prescriptions :

PRN (as needed) medications : Often use q____h PRN _________________

Standing (regular) medications : Often use QD, BID, TID, QID

This makes sense - Generally, docs don't want their patients waking up regularly to take medications at 3:00am.

So I wondered : Could we leverage this pattern to help with electronic order entry?

And then I wondered : Instead of this alternate, Latin-based language which allows doctor-to-nurse and doctor-to-pharmacist communication, but no doctor-to-patient communication ...

could we make a language that everyone (doctor, patient, pharmacist, and nurse) understood equally well?

III. THE COGNITIVE FRAMEWORK :

It seems the real division is between regular (every day) medications and PRN (as needed) medications.

As I mentioned :

EVERY DAY (REGULAR) : COMMONLY USE QD, BID, TID, QID

AS NEEDED (PRN) : COMMONLY USE Q___h PRN ____________

So could we use this to shorten the length of options commonly seen in EMRs for medication frequencies?

And then when doctors, nurses, and hospitals are trying to collect medication histories with the simplest, smallest number of clicks, instead of thinking of :

Or one could even expand the PRN reasons, to turn that same percocet order into "Percocet 5/325mg" + 3 clicks) :

and this could be a form that physician, pharmacist, nurse, and patient could easily comprehend to all speak the same language.

It also guides a physician to avoiding the small issue of "Percocet 5/325mg PO TID PRN mild pain".

And for those other 5% of medications where either there are unique medication times, or when you absolutely need the patient to take the medication every 6 hours and start at 03:00am, you could still click the "FOR OTHER INSTRUCTIONS" box all the way at the right.

I just thought I would share some ideas of how you can help fix your med reconciliation forms and possibly your med reconciliation EMR software, to promote clarity and help reduce clicks. Who knew medical informatics could be so much fun!

Would love comments! Anyone have any other thoughts about the subject? As always, education is a priority, and discussion is welcome!

Wednesday, December 14, 2011

One of the things you get asked commonly, when you work in informatics is, "Are you an IT guy/gal?"

Informatics is commonly confused with IT (Information Technology). But the two are very different. Allow me to explain.

Definitions about informatics vary widely, but I personally take the everyman's, common, "Ernest and Julio Gallo"-type approach - It shouldn't be something that's scary, unapproachable, or unaffordable. I hope to deliver good informatics to your dinner table at a reasonable price in a way that everyone can enjoy. So when I had the opportunity to help, I added the part about "right information to the right person in the right place at the right time in the right way" to the definition in the Wikipedia article on informatics (academic field). Just sounds so much simpler, approachable, and friendly.

This definition still won't make sense to many people, but I'll say this : Informatics may have nothing at all to do with computers. Yes, often informaticists often use computers in their jobs (while planning to save the world!), but some of my favorite examples of informatics have nothing to do with computers.

1. THE FIRST EXAMPLE
The first example of informatics without IT comes from a business professor I had back in college, who did informatics consulting for businesses. He told us this story of a large, popular European furniture company with a quality problem they were having.

The issue, he said, was this : The company had a table they were selling which was often getting returned. Why? "MISSING HARDWARE!" was the most common reason reported by unsatisfied customers.

The company had tried several times to fix the problem on their assembly line, to no avail. Despite their best efforts to remind workers to put all the right pieces in the box, the workers still sometimes forgot.
So reportedly this informatics consulting company examined the assembly line closely :

They focused on Worker #4, who apparently was in the area where the problem arose. His task was to take the Type A bolts out of bag A, the type B bolts out of bag B, and the Type C screws out of bag C, and put them all in the box. But when they studied him, they noticed : He was occasionally forgetting to put in the Type A bolts, occasionally forgetting the Type B bolts, and occasionally forgetting the Type C Screws.

The trick was to get him to remember to put in all three types, every time.

How to do this? They looked to establish something informaticists generally call "cognitive feedback" or "visual feedback" - Where a person gets some immediate feedback/verification of, "Have I done the job right?". And they found the solution in the factory lunchroom, where reportedly the lunch trays just happened to have three pockets in them :

Using a magic marker, they labeled each pocket with an A, B, and C, to create a tool to provide the factory worker with cognitive feedback during his part of the assembly line.

So now instead of taking from bag A and putting it in the box, bag B and putting it in the box, and bag C and putting it in the box - They told him to put from bag A into the tray, bag B into the tray, and bag C into the tray :

Voila! This provided immediate visual feedback/confirmation to the worker that "Yes, you have remembered all three", allowing him to then dump the tray into the box, knowing the task had been completed properly.

And as the story goes, after this change, their quality problems disappeared. All for the price of a $4 lunch tray. The table reportedly ended up being a big hit.

2. THE SECOND EXAMPLE
The second example of Informatics without IT was given to me by the same college professor, who used to do informatics consulting. He was hired to study the waiting times at a large fast-food burger chain. Their issue : "We are losing customers, and can't figure out why." Customers told the chain : "Service is too slow", and no matter what the company was doing to speed up operations, they were losing customers.

This business professor gave me some good informatics advice that still sticks with me today : "The first trick to knowing how to fix a system is knowing how to crash it. Once you know how to crash the system, you'll know how to fix it."

So apparently he and his buddies spent a whole week trying to crash one of this burger joint's restaurants.

They tried spilling food in the middle of the restaurant. No go - Someone came and cleaned it up.

They tried yelling really loud and carrying on. Didn't work. The workers called the police and they were escorted out.

They tried ordering very slowly at the counter. Didn't work. Another cashier opened up and the line moved along.

Then they paid very close attention to the crowd during lunch, and heard someone take advantage of the resaurant's jingle at the time : "Hold the pickles, hold the lettuce, special orders don't upset us." The order they heard?

"Um, I'll have a double cheeseburger, extra-well-done, with extra lettuce, no tomatoes, no onions, ketchup but no mustard, extra pickles."

The restaurant handled this order just fine, but his team noticed that if the person said the order loud enough, during a busy lunch crowd, suddenly everyone else wanted their burger done their way.

So they tried it out the next day, during a busy lunch hour : Two or three of his team ordered their custom burgers, loud enough that people towards the back of the line could hear. It set off a chain reaction that slowed the restaurant to the point where the line went out the door. Customers left in frustration.

Their advice to the restaurant : Lose the jingle. It's OK to allow customers to do custom orders, but if you advertise it, you're only asking for trouble.

So they got rid of the jingle, and reportedly the waiting time went down, and satisfaction went up.

3. THE THIRD EXAMPLE (ROCK & ROLL!)
The third example comes from popular rock and roll culture. Ever heard of the 1980s-1990s rock band, Van Halen?

Van Halen : Informatics Pioneers?

Ever heard of the popular mythology of their concert contract demanding they have no brown M&Ms in their dressing room? As a child of the 80s, I remember hearing about this - It became a little joke of rock-n-roll culture, even parodied in movies like Wayne's World when Wayne gets to walk backstage at the Alice Cooper concert. It's the inside joke of roadies and concertgoers everywhere.

Get ready - It's not a myth! TheSmokingGun.com even has an actual copy of the Van Halen contract rider, which you can read by clicking here. But rather than just juvenile rock-star excess, both TheSmokingGun and Snopes.com go on to explain the real purpose of this request :

The issue was that the band was touring with some very hefty equipment : Large light shows, elaborate sets and music, etc - And there were a lot of technical errors happening. The girders couldn't support the weight of the sets. The flooring would sink in. And despite their contract having very clear instructions of what it would take for the band to perform safely, it seemed people weren't reading the contracts fully.

So by adding the clause :

"Article 126 : There will be no brown M&Ms in the backstage area, upon pain of forfeiture of the show, with full compensation."

it allowed the band to quickly determine if the contract had been read in detail, to give them some confidence that all of the technical specifications had been met.

In other words : They had immediate cognitive/visual feedback about the adherence to the contract and performance of the safety design. An easy way to see failure before it happened!

What genius! (I know David Lee Roth later became an EMT - I wonder if he's involved in HealthIT today?)

So ask yourself : What are your brown M&Ms, and can they help your safety discussions?

It's all about getting the right information, to the right person, in the right place, at the right time, in the right way - Doesn't necessarily have anything to do with computers at all. And hopefully by doing that, you'll help save the world. (Or at least make it a little better place to live.) :)

Friday, December 2, 2011

"Life is a series of hellos and goodbyes, I'm afraid it's time for goodbye again..."- Billy Joel, Songs in the Attic, 1981

So I was thinking more about the challenges with electronic documentation. As I mentioned in my last post, I'm thrilled that people are going to be seeking ways to transmit notes to each other, but I'm just not convinced we have agreement about *what* to send and *when*.

The problem is that healthcare reform is going to center around documentation. So documentation is going to become more important than ever. Knowing :

What and when to document - and...

How to find the right information quickly

... is becoming a key survival skill for hospitals and doctor's offices.

So for today, I wanted to ponder #2 above - (I'm going to ponder on #1 in my next post...)

As part of my job, I teach docs about how-to-find-the-information-they're-looking for. Most EMR software has some system of "filters" you use to narrow down your search to exactly what-you-need.

Sometimes those filters, and learning to use them, can be a little complex, and it's not always the most intuitive. So I wondered - How can we make it more intuitive? I wondered how *I* would graphically re-think a chart - If the chart is all about a patient's life, then why not start with a simple timeline?

(Of course, since we don't really ever know when the end will be, we can just assume the line will have "TODAY" listed on the other side from "START".)

Anyway, during our lifetimes we will all have interactions with people - That's what we want to record. The goal of the medical chart is to document all those interactions.

Some relationships will last for varying lengths of time, all generally starting with a "HELLO" and a "GOODBYE".

It's funny - I think as human beings, our brains tend to remember the "Hellos" and "Goodbyes" much more than we remember the stuff in-between. Anyway, in clinical terms, that "HELLO" is either an "Admission H&P", an "Intake Note", or some sort of a "Primary Evaluation" - And the "GOODBYE" is a "Discharge Summary", "Transfer Note", or some other type of "Signoff Note" :

But of course, if you're following that person regularly, you check in from time-to-time throughout the duration of your relationship. In "best-friend" terms, that's a "stop-by-for-a-visit" or "chat on Facebook". But in clinical terms, these "check-ins" are your progress notes :

The challenge then in documenting your life is that you will have to manage the information about these sorts of ongoing relationships for many people in your life :

And so if they all have an Admission-type note, several progress notes, and a discharge-type note - You already have a large amount of data to keep track of.

And making things more complex is that other people in your life will only be brief but still-important encounters - The cashier you met while withdrawing money while on vacation, the dermatologist you saw once to burn off a wart... Some of the people you interact with in your life will just be single encounters :

Finally, I think it's also important, when re-thinking the medical record, to remember that a patient's life will be punctuated by changes in level-of-care. As long as you have some kind of health coverage, you will always be in one level-of-care or another. (It's even debatable - If you have no insurance, could you still be in an "outpatient setting"? Deep philosophical questions for the healthcare informaticist!) So if we look at the patient's life from this level-of-care perspective, there are definite punctuations which are immediately useful at understanding clinical activities in time :

And so, whoever tries to comprehensively document the life of a patient will have a very complex issue to untangle - Who documented what, and when? :

Fortunately, I think most people think intuitively when inquiring about a patient's life - You either want the whole story, or a part of it. And how much you ask for will depend on your need. Want to admit them for a psychiatric admission? You might be interested in their first childhood pediatric notes. Have a "frequent flyer" you know well? You might just want the notes from the last few levels-of-care. And with computers, it's fairly easy to draw a box over the time period and notes (colors) you want :

Of course, this is somewhat of a jumbled mess - But if the user could help arrange the order of the colors they wanted, they could sort out the mess (by their own individual preference), and then by dragging one box :

... you could quickly select :

The timeframe you need (X-axis)

The notes you need, by your general and immediate preference (Y-axis)

Of course, the colored lines above make it sort of complicated (would some users interpret this to mean the patient had all of these people in their lives throughout the duration of time?), so maybe you would prefer to be able to check off the notes (by profession) you want, as you make your query for documentation :

... and so in this way, you could quickly get to the notes you want - In time, using levels-of-care as a marker, and by specialty. (But remember a common problem with electronic documentation : Sometimes you WANT the doc to see "REALLY IMPORTANT" stuff from a specialty they didn't think to look for, e.g. Case Management, physical therapy, chaplain services - In the paper world, those "REALLY IMPORTANT" things were usually done as a "sticker on the chart" or something like that... It's a little trickier to do that sort of thing with an electronic chart. Who gets to decide what's "REALLY IMPORTANT"?)

OF COURSE, making this sort of a search filter available for your own medical record would depends on some of the following factors :

Having a common (or at least steady) patient identifier, so that someone will be able to assemble all the documentation from all of these different clinical people you interact with.

The ability to mark documentation with not only the author, but the profession/specialty they represent.

Being able to mark changes in level of care across a healthcare delivery system.

... so I'm not counting on seeing this in any software tomorrow - But I think it's potentially another way to look at the mass of information about a patient and quickly get what you want in an intuitive way.

REMEMBER : WITH FREE OPINIONS, YOU GET WHAT YOU PAY FOR. :) Always glad to hear from people - Feel free to leave thoughts and comments! :) In my next post, I'm going to ponder about "How much documentation is enough?" - Stay tuned! :)

Tuesday, November 15, 2011

So I've recently been looking at some of the most important standards we have, that few people appreciate. Some standards that I've recently been admiring the beauty of :

The 110-volt AC plug in America - Thank goodness for this! Imagine if you had to worry about which coffee maker you could or couldn't buy because it didn't have a plug that fit your house! (Or even better, think about how challenging it is to travel with that same coffee maker to a different country!)

Traffic lights - Thankfully, they all behave the same in our country. Imagine if driving from Maine to Florida meant having to learn different traffic signal patterns?

Traffic patterns - We all drive on the right side of the road in the U.S. - Imagine having to change as you drove state-to-state? (I wonder how they handle this in the Chunnel between France and England?)

Train tracks - Snopes.com has this interesting debunking about railroad gauge, that includes a mention of how during the American Civil War, the northern railroads had one gauge while southern railroads had multiple gauges - this was argued by historian James McPherson to be one of the logistical factors that contributed to the Union army winning over the Confederate army. (And interestingly, after the North won the war, many of the southern railroads were rebuilt by the North, giving us the American standard of 4 feet, 8.5 inches.

The Apple iPhone/iPad/iPod charger - Although Apple toyed with some of the charging pins since the iPhone 3G, the plug has essentially been the same since the original iPod in 2001. Now it seems that since the iPhone 3G, you can use the same plug to charge your iPhone 3G, iPhone 4, iPhone 4S, iPad, iPad2, iPod Touch, and various other apple devices. I suspect this is why the plugs are becoming so ubiquitous that most of my friends now seem to have one in the kitchen just to let visitors charge their Apple devices.

American Standard Code for Information Interchange (ASCII) - This is arguably much larger than just an American standard - Although Unicode has expanded the ability for designing documents, ASCII is probably the most widely-used standard in computing. Can you imagine if your processor didn't know you pressed the "A" key on your keyboard? What if that "A" didn't show up on the screen? What if you sent an email and the "A" didn't arrive?

Internet Protocol (yes, both versions 4 and 6) - The Internet would not be possible without a standard Internet Protocol.

So I think we can all agree that these standards are good for us - And thankfully for healthcare, the ANSI (American National Standards Institute) created a new HITSP chapter in 2005 after the ONC recommended someone start working on healthcare IT standards. (A shout out and thanks to John Halamka, MD for taking on this labor of love!) :)

Anyway, I think the take-home message about healthcare IT standards is that we're still really early in the process. (As of this writing, the HITSP has only been around for about 6 years!)

So because a lot of my work as an informaticist deals with the struggles to achieve standards, I think a lot about the final objective of informatics : Getting the rightinformation to the rightperson in the rightplace at the righttime in the rightway. (It's easy to get 2 or 3 of those right, but getting all 5 right is much more difficult.)

In my quest to get the right information to the right person in the right place at the right time in the right way, it dawns upon me that the best technical solutions may still fall short of expectations because of this : There aren't really any good standards for the content of electronic documentation.

In fact, I started to ponder - What standards are there, at all, for clinical documentation?

Most practicing physicians can pretty quickly think of one real standard - The SOAP note. It stands for "Subjective, Objective, Assessment, and Plan", and is a rough outline for how you write a note in a logical way :

S - Subjective- What you heard from the patient (history, opinions, and answers)O - Objective - What you saw about the patient (measurable things or physical findings) A - Assessment - What you believe is currently going on with your patientP - Plan - What you and your patient are going to do about it

The SOAP note is also a cognitive framework for how we think and communicate about patients - When you sign out to another physician, the SOAP note influences our thinking and what we say or write about our patients. By forcing a physician to confront the evidence (S, O) before rendering an opinion (A) and plan (P), it has had a remarkable impact in improving the quality of care and communication about that care.

Interestingly, the history of the SOAP note goes back to this seminal paper written by Dr. Lawrence Weed, published in the March 14th, 1968 edition of the New England Journal of Medicine. (Click on the link above to read the actual article.)

** IF YOU WORK IN HEALTH INFORMATICS, YOU SHOULD READ THE ORIGINAL ARTICLE IN ITS ENTIRETY. **

One of the fascinating parts about this article is in its opening paragraphs - The purpose of this paper, in 1968, was "...to develop a more organized approach to the medical record, a more rational acceptance and use of paramedical personnel and a more positive attitude about the computer in medicine." Snark Alert : Amazing how far we've come in the last 43 years!

But getting back to serious discussion, the paper highlights many of the struggles we have had with implementing EMRs in the last 40 years - And still continue to struggle with today. When you read the article and see how notes were structured BEFORE the SOAP structure, you can see why some people argue he should win a Nobel Prize for Medicine.

But then I thought : We have the SOAP note - But do we have anything else to help guide us?

Since most medical schools teach little about clinical documentation (you're usually too busy learning about diseases), many doctors finally learn about note writing from pocket books like the Washington Manual Intern Survival Guide. (Similarly-themed but shorter "Intern Survival Guides" can be found here and here, just to get an idea of what I'm talking about.)

So if most of our education for physicians about writing notes falls down to these pocket guides, and the notes are often specialty-dependent but built on the SOAP framework - It's no wonder we all struggle with electronic documentation.

A WORD ABOUT THE STRUGGLES OF ELECTRONIC DOCUMENTATION

Anyone who has worked on electronic documentation will tell you : It's hard to build, and hard to maintain.

The first challenge is getting a note built - What exactly will you use the note for? What will you name it? What do you want to include in the note?

Looking for answers to these questions often depends on :

The planned clinical scenario

The physician's experience

The physician's pocket guide they learned from in Internship

Regulatory and compliance issues (the stuff that insurers and other regulators want to read about)

The funny thing is, every hospital is working on this same problem separately - Often coming out with similar but slightly different results. It's a great example of "everyone rebuilding the wheel".

Why can't all Medicine History and Physicals look the same? In my experience, most of them approximate the same SOAP format, but I've even heard the argument, "I'd like to see the Plan at the TOP of the note when I read it." This speaks to a challenge of documentation in general -

Documentation is closely tied with our cognitive processes.

Our cognitive processes, while similar, are not entirely standardized.

Regulations, insurer demands, and clinical practices change frequently, making it important to maintain notes after they're built.

So in the end, clinical documentation is more expensive to build and maintain than most people imagine - And every hospital is having the same struggles together.

And because the notes may vary in their end result - An electronic note sent from a doc in one hospital one day may not have the best reception by the physician at another hospital.

In other words : I'm thrilled we're working to link our EMRs - But will the notes we send be equally effective at another hospital?

THE INTERSTATE-91 INFORMATICS PROJECT

So we have a new, small, informal group of volunteer healthcare informaticists here along the Interstate 91 Corridor that stretches between New Hampshire/Vermont, all the way down through Massachusetts to New Haven, CT. We meet informally every 3-4 months for dinner to discuss healthcare informatics, and I'm glad to report we recently obtained a donated website, which we hope to develop.

I'm hoping at our next dinner to propose a few crazy ideas to our group :

What if all of our documentation looked the same? (for the same clinical scenario...)

Could all of our clinical documentation look the same? (for the same clinical scenario...)

Could we develop a standard for content of electronic documentation?

Could we help further develop the SOAP note, to provide a logical and cognitive standard that helps improve care and reduce costs for all of us?

Could this framework be used as a teaching tool about clinical documentation in medical schools and residency programs?

Will let you know how things turn out after our next dinner. Look out for the I91 Standards. :) (Ooh, another cliffhanger, I know!)

As always, I love to answer questions. Feel free to respond with thoughts, questions, ideas, or other discussions. Remember : Education is a priority! :)

Saturday, October 15, 2011

So in my last post, I discussed the "patient identifier problem", and how it contributes to poor connectivity between systems. I discussed some of the political problems with sharing health information, and some common, differing perspectives. I also briefly discussed some of the models being developed, including NHIN/Direct (now officially called "The Direct Project").

One thing I forgot to mention that makes this all more complicated are the myriad of privacy laws - Not just HIPAA, but also various state laws about transmitting or even storing data about HIV and other transmissible diseases.

The challenge is then, how do we overcome these issues in the US?

There are a lot of issues to be worked out, clearly, but I think one of the major issues is simply making organized change with all of these political, financial, and technical obstacles in place.

I. WHO'S THE BOSS?

So let me first ask - Who's the most powerful person in healthcare?

I sometimes ask friends and family this question, and it's interesting to hear people's guesses. "Obama?" "Hillary Clinton?" "The insurers?"

My response : It's the patient.

I think people forget : The patient is the boss. They are the ones who pay the tab for healthcare, whether it's the insurance premiums they pay, or the taxes they pay... They are the one making the choice about where to go, and so they have enormous influence about who succeeds in healthcare.

When it comes to healthcare reform, there is often talk about laws, and doctors, and insurance companies, and nursing unions, and medicare and medicaid - But I think patients are an untapped resource in the healthcare reform discussion.

The problem is that, from my experience, a lot of patients are sort of like the substitute teacher we all had in grade school - Even though they are technically in charge, they're new, they just showed up today, they don't entirely understand the routine, and so they sometimes lack confidence and can be subject to "But-Mrs.-Smith-we-ALWAYS-have-three-hours-of-recess"-type arguments that sometimes steer them.

So I've often wondered - What if a group of coordinated, informed patients could really assert their power?

II. COORDINATING A CHANGE

The problem is, as I said, most patients are too new, or too inexperienced to know what to look for. When doctors and nurses become patients themselves, they can be some of the most challenging patients - Why? Because they know what to look for and how to assert their power.

So then I wondered - Could we somehow train all patients to know what to look for? Could we get patients to ask for different care? How would they know what to ask for?

So I thought - To help patients assert their power to make change, we need to make it easy for them to ask for change.

So then I thought of solutions. For those readers who are multi-lingual, or amateur linguists, you'll appreciate this : Language is fluid. It's not as precise as most people think. Even though modern English has been around since about 1550, linguists know this : words enter and leave the lexicon all the time.

So what if we employed a linguistic feat and came up for a new word for this new type of healthcare? Something evidence-based, efficient, affordable, and connected?

How could we get patients to ask for this type of healthcare? What if we could get lots of patients to ask for this type of healthcare?

III. DEVELOPING THE STANDARD FOR INTERCHANGE

The first trick is, defining a standard for this future model. From the ground up, the new healthcare paradigm has to be built. The informational framework for healthcare has to be laid to allow hospitals to run efficiently, and for patients to be able to - only if they wish - bring their data with them. That is, one patient = one chart. So when a patient moves from one office to another, the systems will talk to each other and allow true data portability - Without having to push or pull the data.

Why would a patient want a standard for data portability? Why would they care that other doctors can read their chart from another hospital?

It reduces errors (because doctor A knows what doctor B has been doing)

It reduces waiting times (because doctors don't have to spend time trying to research your history)

What if we could make a standard for data portability? Obviously, many patients would refuse, citing personal privacy reasons - But would other patients ask for this?

IV. THE SPEAKFLOWER PROPOSAL

The next trick would be, naming the standard something easy. A lot of "Health IT standards" have names like HL7, CCR, CCD, LOINC, DRG, ICD-9, etc.... Not too tangible to the average patient.

But what if we named this standard something really warm and friendly and tangible... Like "SpeakFlower"?

In other words, "SpeakFlower" is a placeholder for a standard that allows a patient to ask for a doctor/hospital/office to have all of their medical records transferred to a central site that the patient controls, so that other doctors could look at it in the future. It means not only building a particular HealthIT standard into the EMR, but also adopting the practices needed to employ it.

Could we get patients to ask for SpeakFlower? What if they did?

V. SELLING THE CONCEPT

The joke goes, "Standards are like toothbrushes - Everyone knows what they are, but nobody wants to use yours." We have lots of different EMRs, and a few standards, and yet there doesn't seem to be universal agreement on which standard to use, and how to use them.

Why? I think there are a lot of reasons - Complexity of our healthcare system is one, but there's also privacy issues and a lot of competing financial interests. In the end, fighting for a national standard is very challenging.

So what if a coordinated group of patients developed a 100% optional, national standard and how to use it? And what if they called this optional standard SpeakFlower?

Could we sell this concept of an optional national standard? I think so.

After developing the SpeakFlower technical framework (HealthIT standards, central servers, HIPAA-secure gateways, etc.) - You then need to teach patients about SpeakFlower. And how to do this?

Imagine a commercial on the Superbowl, where Wilford Brimley comes out and says :

"You know, my primary care doctor almost ordered something that interfered with something my cardiologist gave me last week, because she didn't know what my cardiologist had prescribed. And my cardiologist almost ordered a test I had last week in the ED because he didn't know what the ED doctor had done. And all of these extra tests, bills, and waiting time are really getting me down... But now, with SpeakFlower, all of my doctors can share my information easily and I get to keep track of it. So ask your doctor... Do you SpeakFlower?"

Why Flower? Because flowers are ubiquitous. They come in every shape and size, are found in every country in the world, and no matter what it looks like, it's still a flower. Flowers are friendly, peaceful, and represent growth, life, and vitality. This optional standard that patients might ask for should represent peace and life.

Oddly enough, if you diagram the model that puts the patient at the center of the medical record, and have all of the providers/hospitals/labs/pharmacists as connections to the patient in the center - The diagram almost invariable ends up looking like a flower.

Why speak it? Because like a person trying to communicate in a foreign language, we might ask for someone to speak the language we know. Asking to SpeakFlower is asking a doctor/hospital's EMR to speak a particular language - It says, "Please have your EMR speak the language I need to accomplish the goal I'm asking for."

VI. REALLY?

The hope would be that simply discussing an optional, national standard for healthcare data interchange would be enough to get all vendors, doctors, and hospitals to adopt the standard and implement itfor those patients wanting their charts to be portable. It would also help simplify the privacy discussion, because patients would actively seek out SpeakFlower - Makes the whole discussion on "opt-in-or-opt-out?" much simpler. It would also allow docs and hospitals to generally keep their legacy systems - Implementing SpeakFlower does not require painful amounts of programming, just adherence to the SpeakFlower standards.

But if the discussion wasn't enough, then the hope is that the Wilford Brimley commercial on the Superbowl could spur the discussion - in the same way pharmaceutical companies have gotten patients to ask for drugs, patients could start showing up saying, "Dr. Stanley, do you SpeakFlower in your office?" and have an understanding of the benefits of SpeakFlower.

And even if 30% of my patients asked me to SpeakFlower, I'd probably have little choice but to make sure my EMR SpokeFlower, for those patients requesting it. So I'd speak to my vendor and ask them to make sure my EMR can SpeakFlower.

VII. SPEAKFLOWER TODAY

If only...

There is a SpeakFlower.org web site, which I started to develop with two colleagues in our spare time, but you'll notice the web site is outdated and quite frankly, we realized planting SpeakFlower in our national garden would require much more time and capital than we currently have. (Namely, weekends and nights.)

But we're still trying to build it and transplant it to the right FlowerPot. Our hope is to make SpeakFlower a force of good in healthcare. We also have a #SpeakFlower hashtag on Twitter that we apply to tweets that discuss patient-centered electronic medical records.

Healthcare needs innovative ideas. If you're interested, follow @SpeakFlower on Twitter, feel free to use the #SpeakFlower hashtag, and look for the SpeakFlower gardening team as we look for the right pot to plant in. :)

So at first glance, it should be easy to identify a human being. After all, we have names, right? When we see our neighbor John mowing the lawn, riding his mower - His name is John - We recognize him - Yep, that's him. Easy, right?

Well the problem is what happens when we actually try to identify someone on paper - That is, have a record that we can match to an actual human being.

At first, we might try to label a chart "John's Chart". The problem with this approach is that there may be lots of Johns, so in a small town (even on a small street), you might have two "John's Charts".

So you might add the last name : "John Smith's Chart". This might work in a small town, but when you expand to collect charts for your whole state, or the whole country, you might find over 700 "John Smith's".

So names are generally a bad way to label a chart for a few reasons :

There might be over 700 "John Smiths" across the country - How will you know which chart is the right one to look for?

Your neighbor, John Smith, might register at Clinic A as "John Smith", at Clinic B as "Johnathan Smith", and at Clinic C as "Jon Smith". This could potentially make three records. How will you know which is the proper record to search for?

Names may also be misspelled by registration staff - If a "Karen" registers in a clinic, will the registration staff write "Karen", "Caryn", "Karin", or "Karyn"?

Ethnic names, over a large country, also may suffer from the poor understanding of the host country. How exactly does one spell Dimitry? Dimitri? Dimytri? Moroch? Morocz?

So one might try to straighten this out with some simple recipe - One I often hear first is, "Why not use the first three letters of the first name, first three letters of the last name, and the date of birth?"

The problem with this approach, again, is that someone might register with a different name in a different clinic. Is it going to be "JOHSMI01011970" (John) or "JONSMI01011970" (Jon)?

Then the suggestions usually continue...

Q : "Dirk, what about by the Medical Record Number?"

The medical record number for this patient at your hospital (123456) may not be the same as the medical record number for the office down the street (654321).

Local medical record numbers might work for a hospital, or a small regional group (if you have centralized registration), but they generally don't work across different healthcare systems.

Q : "Hmmm... Why not use the social security number to identify people?"

The social security number suffers from a few problems too :

There is no check-digit in the social security number. A check-digit is a number (or series of numbers) that are mathematically linked to the other numbers, so you can figure out if the number has been falsified. The social security number was invented back in 1935, before things like "identity theft" were around. As a result, the social security number is probably one of the most abused identifiers, often used for fraud by criminals.

The social security number is a 9 digit number - So in total, we should be able to issue about 999,999,999 of them, BUT... because of certain restrictions (e.g. no numbers that start with 666, no numbers with -13- in them, no numbers with all of the digits the same), there is really only a pool of about 820 million to draw from. Currently the U.S. population is about 350,000,000. Which sounds OK, except that we maintain that number by having some people die every year, and some new babies added every year. In total, about 620 million numbers have already been handed out, so we could potentially run out of social security numbers sometime around 2100. Yes, that will be some time from now, and hopefully we will be able to fix that before it happens - but in our current political climate, will the government ever be able to assign a personal identifier again?

It's funny - I've spoken to informatics people around the globe, and they usually ask me "Dirk, why are you guys in America having so much trouble getting a national health record? In our country it's very simple - Either :

"...our national government maintains our national health record."

... or ...

"...our national government assigns a health identifier for all citizens."

Q : "So Dirk, how does the VA (Veteran's Administration) do it? I heard they saved lots of money through their VISTA/CPRS medical record, and their record is a major source of data for reasearch."

The VA essentially has a national patient record because, well, most veterans have a different opinion. When you ask most vets, "Do you care if the government has a number to track you?", they say things like "No, the government has been keeping a file on me since the day I enlisted!" right before they rattle off their rank and military ID number from memory. In reality, the VA has also been using Social Security numbers, but I understand there is currently a movement underfoot to move away from those identifiers to another number - I'm not an expert on the VA architecture, but this might explain why they divide the VA record up into different VISN systems. (Any VA Informatics people reading this willing to help explain the architecture?)

In short -

The culture at the VA supports a nation-wide medical record number.

The culture of private and teaching hospitals (the "rest of America") does not.

This is why, when I get asked :

Q : "Dirk - The VA has free EMR software - Written by the government, so it's public domain - Why don't private hospitals use it?"

I usually answer, "Private hospitals *could* use it, but because of these culture differences they probably wouldn't see the cost and efficiency benefits that the VA did."

(In reality, there are also other support reasons why a private hospital might not implement CPRS/Vista - But that might be changing some with cool open-source projects like OpenVISTA.)

Q : "So Dirk, is there any hope for a national EMR? Will patient data ever be truly portable?"

Well, currently there is the NHIN/Direct project (see http://www.directproject.org and http://wiki.directproject.org) which seeks to allow physicians to transmit patient data, securely, between different offices - But without a common patient identifier, this may not have the workflow some patients and most physicians ideally want. Still, it would allow a maximum of privacy and patient control, and it's at least a step in the right direction.

There are also a number of regional Health Information Exchanges currently in use, and new ones being built - But without a common patient identifier, nobody seems to be sure about how this is going to work on a bigger, national level.

So yes, if you're traveling from Texas to NYC for vacation - You had probably better bring your medication list and medical history written on a piece of paper, just in case you need medical care.

Finally - I think there is actually some hope for a solution to this that could fly politically in America. I've tested the idea with both republicans and democrats and oddly, both seem to like it. It's called the voluntary patient identifier. Unfortunately, I think so far this effort suffers from poor understanding, poor marketing, and quite frankly, poor patient interest.

But I think there is a way to change that - I'll describe it in my next post.

Thursday, September 15, 2011

Ever wonder where your orders go? One of the things I do when training a doc on CPOE is explain to them the basic medication delivery workflow in a standard hospital. When a doc "goes CPOE", he/she is suddenly confronted with some hard realities of the ordering process - Exactly what they order, and exactly how they order it, will largely determine their success in getting a drug at the right time in the right place.

(PLEASE NOTE WITH THIS DISCUSSION : YOUR MILEAGE MAY VARY GREATLY - This workflow is a general summary, but lots of other hospitals may do things differently, and for a very good reason - I'm just summarizing some general themes, but for specific information, ask your directors and informatics staff.)

So I usually start to frame the discussion with the basic unit of care - A doctor, and a patient. (You'll notice these slides borrow from my piece on "What is Med Reconciliation, anyway?", where the physician and patient lovingly spend time with each other in an area I call the "patient care cubicle") -

Inside a hospital, this "patient care cubicle" is an "inpatient care cubicle".

Outside a hospital (or in an ambulatory setting like an ED or day surgery), it is an "outpatient care cubicle".

Let's focus first on the inpatient care cubicles, where a lot of medications are ordered as patients are admitted into a hospital :

It's first important to consider how exactly an order is created. If the doctor and patient are sitting next to eachother, then the basic unit of care (from the physician perspective) is the physician order - On this slide, it's labeled the "MD ORDER".

First, let's look at this "MD ORDER" for a medication in the INPATIENT setting :

I. MD ORDER FOR A MED : THE INPATIENT SETTING

There are then basically three different ways a med order can come into existence :

As a written order - This is an acceptable way of making an order - Even the VA, during downtimes, allows written orders. Most hospitals with EMRs still allow some form of written orders for downtimes or other complicated orders. The problem : This type of order requires a nurse or pharmacist to transcribe it, so if the doctor has poor handwriting, this can result in a small percentage of error.

As a telephone / verbal order - This is also an acceptable way of making an order, especially if the physician's hands are tied up doing a procedure or surgery. The problem : This type of order also requires a nurse or pharmacist to transcribe it, so if the doctor doesn't speak clearly, this too can result in a small percentage of error. ("Did you say Metoprolol 15 or 50mg?") Another problem : This legally requires a physician to go back and sign this order afterwards - This is very complicated and time-consuming for most physicians.

As a CPOE order (Computerized Physician/Provider Order Entry) - This is the entry method preferred by most hospitals, regulatory bodies, and the government. I suspect this is primarily because there's no intermediary who needs to transcribe the orders, so there is the common belief that this is less error-prone. I haven't seen really good data about this yet, but I do believe that good CPOE requires good training. There is also some data to suggest total medication turnaround time decreases with CPOE use - See this HHS piece on Medication Turnaround Time.)

So no matter how a physician creates the order on the floor, the order gets made. Let's say, for our little example, that the order is "Ativan 2mg IV x1 dose STAT".

Any idea where the order goes next? If you guessed "Pharmacy", you're right!

Whether you're in an electronic hospital, or a paper hospital, Joint Commission requires all inpatient medication orders for acute care hospitals to be "verified" by pharmacy. ("Verify" is basically a fancy word for "double check".)

So a pharmacist suddenly sees the medication order - "Ativan 2mg IV x1 dose STAT". And there are a few things a pharmacist can do to try to help ensure the safety of this order :

They can check the allergy profile of the patient.

They can check the dose of the drug.

They can check for drug-drug interactions.

In some hospitals, they can even sometimes do fancier checks, like check the renal dosing of the drug, weight-based dosing of the drug, etc. (this sometimes varies considerably, depending on the types of services offered)

What pharmacists can't really do well is verify the need for the drug - They usually aren't sitting in front of the patient, with the patient's chart - So if you order heparin on a patient with a bleeding ulcer, a pharmacist is probably not going to be able to prevent that type of error. (Nurses, usually right in front of the patient, are generally much better at finding that sort of error.)

Anyway, after a pharmacist does his/her best to verify the safety and dosing of the order, or adjust the order, they generally click a button to "verify" the order, and then the order travels back to the floor where it does two things :

This then allows a nurse to take the drug out of the Pyxis drawer, give the drug, and chart it on the eMAR. Once it's charted, that's generally when a hospital gets to generate a bill for having given the drug.

So that's generally the way it works in the inpatient world.

Any problem with this pharmacy verification workflow? Having a pharmacist double-check the orders helps reduce errors, so ... Is there any drawback a doc should be concerned about?

Well, imagine if you had a patient seizing in front of you, and you had to give them the "Ativan 2mg IV x1 dose STAT". How long exactly does it take a pharmacist to verify those medication orders?

The interesting thing is that there are actual guidelines about this (these are approximate - Your state/region may vary on this) :

So if the regulations are typically around 30 minutes, and even if your inpatient pharmacy can do it in 5 minutes, can you wait 5 minutes to give a seizing patient ativan?

The answer, of course, is obviously no. So what can you do? You generally have two choices :

OPTION 1 :Call the pharmacy and say "I just put in an order for Ativan - Can you verify it ASAP so the nurse can take it out?"

OPTION 2 :BYPASS the system. In most hospitals, a "Code Blue" (or "Rapid Response") is a perfectly acceptable reason for a nurse to hit the "Emergency Bypass" button on most Pyxis machines - This allows a nurse to get the drug and give it in an emergency.

Note that most Pyxis machines actually TRACK the number of times they have had an emergency bypass - There should be a valid reason to bypass this important safety mechanism, so a unit where there are more emergency bypasses than needed/expected may be a cause for concern and investigation.

So that's generally the way medication orders get created, verified, and followed in an inpatient setting.

II. MD ORDER FOR A MED : THE OUTPATIENT SETTING

Here's where it gets interesting - That pharmacy verification thing? Joint Commission, on seeing the success of this in reducing errors, thought 'Wouldn't it be nice to have pharmacist verification in the OUTPATIENT setting (e.g. Emergency Department, Surgical Daycare, etc?)'

And do you know what happened? Most emergency departments, for good reason, argued "We can't handle the time delay of verification!" - And so, as of yet, it's not a mandate to have pharmacy verification in the Outpatient setting. (Perhaps for good reason - The delays it could cause could create a whole different set of problems.)

So how exactly *does* it work in the outpatient setting?

ORDERING : Generally the same process - A doctor can use either :

Written order (same as above)

Telephone / Verbal order (same as above)

CPOE order (same as above)

The difference is, however, that without pharmacy verification, where exactly does the order go?

In most hospitals with electronic systems, then, this order then will simply go to the eMAR. (It makes a space in the software for charting the administration of the drug.)

So then the typical workflow is this :

Nurse sees order in EMR or eMAR

Nurse opens Pyxis (in most EDs, the Pyxis will open up automatically)

Nurse gives the drug

Nurse charts the administration on the eMAR

Again, after charting the administration, this usually lets a hospital generate a bill for having given the drug.

So in most Emergency Departments (mostly for reason of avoiding delays), there is no pharmacist between the doctor and the nurse part of the workflow. There are still two people double-checking every order - The physician, and the nurse.

III. SO WHY DO I CARE?

The reason you, as a physician, might care about these workflows is that often, inpatient doctors are asked to admit patients from the Emergency Department.

And how exactly does a computer know which workflow to follow - The inpatient or outpatient workflow?

Let's recall - In both settings :

The physician usually places the order via written, telephone/verbal, or CPOE methods.

The nurse usually gives the drug to the patient

The nurse usually charts the administration on the eMAR.

So how does the computer know whether to follow the inpatient or outpatient workflow for a medication order?

Q : "Dirk, is it by physician type? Like, orders from ED docs follow the outpatient workflow, and orders from Hospitalists or other inpatient docs follow the inpatient workflow?"

A : Usually not. If systems were built to do that, then a Hospitalist would have significant challenge in running a code on a patient physically located in the ED.

The answer is usually, as we say in New York, "Location, location, location." That is, the location of the patient determines which workflow most EMRs will use on the order.

So for example - A patient in a location, and the workflow :

ED Room 1 = Outpatient

ED Room 2 = Outpatient

ED Room 14 = Outpatient

ED Holding Unit = Inpatient *

Room 125B = Inpatient

Room 202A = Inpatient

ICU Bed 3 = Inpatient

ICU Bed 4 = Inpatient

* - Remember - Most holding unit beds are actually an inpatient level of care, and so they follow the inpatient workflow.

IV. AGAIN - WHY DO I CARE?
There are a few reasons why I teach this to the docs I'm training on CPOE. They are :

You are going to be a working doc - You need to know how to troubleshoot the system, just in case of emergencies.

You might admit someone from the ED to an inpatient bed.

Reason #2 is especially important for Hospitalists and other inpatient docs to understand. Why? Because if you are admitting a patient, and the computer still shows the patient to be in an ED bed (e.g. ED Room 1), then those orders entered into your EMR may not be verified by pharmacy - Orders not verified by pharmacy means the Pyxis machine won't open up when the patient gets up to the floor. This is when you get that call from the nurses : "Dr. ____________, remember those orders you put in while the patient was in the ED? For some reason, the Pyxis machine isn't opening up now - Can you re-enter those orders in the computer?"

This, of course, leads to delays and frustration. So what's the best thing you can do as an inpatient doctor, if you get called by the ED to admit a patient to your service?

1. First, go down to the ED and see and evaluate your patient
2. Look on the computer at their location -
- If it says "ED Room 1" - Ask your registration to change their bed to an inpatient location.
- If it says "ED Holding Unit" or "125B" or "204A" or "ICU 3" - Go ahead and start your orders.

Again, please remember - Your hospital's workflows may vary - This is a gross generalization for teaching purposes only. Please ask your local regulatory agencies, your local administrators and directors, and your local informatics people for more details about the workflows in your hospital.

Hope you enjoyed this post - Feel free to send questions, I love the feedback and I'm always glad to create posts to answer them!